The Coalition for Patient-Centered Imaging (CPCI), representing physician and other health care provider organizations dedicated to high quality imaging, is extremely disappointed by MedPAC's June 2011 recommendations to Congress, which could negatively impact patient access to high quality, cost effective options in imaging and diagnostic services. Furthermore, our organizations are deeply concerned that MedPAC's recommendations, if implemented, would undermine efforts to promote the delivery of integrated, patient-centered care that could improve outcomes and help curb rising health care costs.

Over the years, legislative and regulatory changes have led to significant cuts in Medicare payments for advanced imaging and other diagnostic imaging procedures. As justification for yet another round of cuts in these services, MedPAC has pointed to "rapid volume growth" of 6.3% per year in the volume of these services per fee-for-service Medicare beneficiary. This ignores the fact that the volume of imaging services provided outside the hospital began trending downward in 2007, and in 2010 volume for both standard and advanced imaging services per fee-for-service beneficiary actually fell below the 2009 levels. Advanced imaging services also are shifting out of physician offices and into more expensive hospital outpatient departments, suggesting that another round of imaging cuts is not only unnecessary, but would also be counter-productive to efforts to integrate the delivery of care and to address the impact of rising costs on our nation's health care system and our country's deficit.

We have specific concerns about the potential unanticipated consequences of MedPAC's recommendations:

Of serious concern is the recommendation that seeks to penalize physicians when they order a test for their patient and then perform and interpret it in their own office. This recommendation goes well beyond any previous restrictions on physicians' ability to provide diagnostic testing in their own offices, and would substantially interfere with physicians' ability to utilize imaging along with other clinical information to diagnose their patients accurately and expeditiously. Unjustified reimbursement cuts to physicians in office settings would encourage these physicians to refer their Medicare patients to higher cost hospital settings and to rely on study interpretations performed by physicians with no knowledge of the patient's clinical condition. If enacted, this recommendation would seriously impact provision of x-rays and ultrasound services to Medicare patients, and could significantly reduce Medicare payment to primary care physicians.

MedPAC's recommendation to extend the current across-the-board multiple procedure payment reduction to physician interpretation is also problematic. In many cases, any efficiencies involved in performing multiple imaging procedures at the same time already have been addressed through revisions and revaluations of affected services, which results in more accurate pricing than across-the-board reductions of the type recommended by MedPAC. We disagree with MedPAC's assumption that there is significantly less physician work required when there are multiple tests performed and believe the manner in which the AMA Specialty Society Relative Value Scale Update Committee (RUC) is reviewing this issue is much more deliberate, precise and equitable.

The recommendation that would mandate prior authorization of certain advanced diagnostic imaging services is also concerning. Prior authorization would result in increased costs for the Medicare program and for affected practices, and unnecessary delays in the provision of care to Medicare beneficiaries. A recent AMA survey showed that 63 percent of the 2400 physicians responding typically waited several days for a response to prior authorization requests and 13% generally waited more than a week. In addition, targeting physicians for review based on absolute numbers of studies performed ignores factors such as practice volume, differing patient demographics, geographic variation and clinical complexity case mix. Efforts to use prior authorization in Medicare were tried before, determined to be useless, and abandoned. A better approach for assuring appropriate use of imaging is to promote application of appropriate use criteria. Congress has already authorized a two-year demonstration to assess the appropriate use of imaging services furnished to Medicare beneficiaries and the results of this demonstration should be evaluated before other options are implemented.

We look forward to working with Congress to ensure that any future policy changes affecting diagnostic imaging take into account the substantial changes that already have been implemented by CMS, by Congress and by diagnostic imaging providers, and ensure that patients retain access to diagnostic services performed in physicians' offices.

American Academy of Neurology

American Academy of Ophthalmology

American Association of Clinical Urologists

American Association of Neurological Surgeons

American Association of Orthopaedic Surgeons

American College of Cardiology

American College of Rheumatology

American College of Surgeons

American Gastroenterological Association

American Society for Neuroimaging

American Society of Echocardiography

American Society of Nuclear Cardiology

American Urological Association

Association of Black Cardiologists

Cardiology Advocacy Alliance

Large Urology Group Practice Association

Medical Group Management Association

Society for Vascular Surgery